The KHIT Blog

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Emergency Department Visits For Firearm-Related Injuries In The United States, 2006–14ABSTRACTFirearm-related deaths are the third leading cause of injury-related deaths in the United States. Yet limited data exist on contemporary epidemiological trends and risk factors for firearm-related injuries. Using data from the Nationwide Emergency Department Sample, we report epidemiological trends and quantify the clinical and financial burden associated with emergency department (ED) visits for firearm-related injuries. We identified 150,930 patients—representing a weighted total of 704,916 patients nationally—who presented alive to the ED in the period 2006–14 with firearm-related injuries. Such injuries were approximately nine times more common among male than female patients and highest among males ages 20–24. Of the patients who presented alive to the ED, 37.2 percent were admitted to inpatient care, while 8.3 percent died during their ED visit or inpatient admission. The mean per person ED and inpatient charges were $5,254 and $95,887, respectively, resulting in an annual financial burden of approximately $2.8 billion in ED and inpatient charges. Although future research is warranted to better understand firearm-related injuries, policy makers might consider implementing universal background checks for firearm purchases and limiting access to firearms for people with a history of violence or previous convictions to reduce the clinical and financial burden associated with these injuries.

My response on Facebook:

Very good. But, we have to add to those data all of the postacute care stuff. Relatedly, how about all of the expenses associated with law-enforcement and other first responders? Not to mention the myriad n-dimensional legal expenses.

Beyond all the unquantifiable tragic, searing human miseries, what about the broader adverse economic impacts? apropos,

As reported by CNN, NOAA estimates the aggregate cost of 2017 U.S. natural disasters at $306 billion. I can't help but wonder how much of that is reflected in the "recent GDP growth" that Donald Trump never fails to brag about?

I can't help but feel that the Health Affairs article seriously understates the overall financial impacts of these shootings. We can be sure that the NRA will not let the government do any precise analytical studies on the topic -- "that I can tell you."
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The President stopped by in Parkland on his way to Mar-a-Lago.

I'd tweeted this:

That was before I saw the photos.

Barron Trump will most certainly never face the muzzle of an assault rifle while at school

POTUS PRIORITIES...

AN "INHERENTLY DANGEROUS INSTRUMENTALITY?"

The (tobacco industry) analogy is a bit of a stretch, I know (and I know that some of my "gun enthusiast" friends will scoff). But, not that much of one. A "perfect analogy" is essentially a redundancy, anyway. Relevant similarities are what matter.

In civil tort terminology, the “Inherently Dangerous Instrumentality” is one for which there is no "safe" use. “Used as directed,” it harms or kills its customers (e.g., tobacco products; not even mentioning the tangential effects of “second-hand smoke”). Cigarettes were finally found legally to be ‘inherently dangerous instrumentalities” (notwithstanding that many users were/are not made diagnosably "ill" or killed by smoking). While that designation did not outlaw tobacco products, it laid the foundation for by-now settled legislative and regulatory actions.

While, yes, a firearm can be used “safely,” the projectiles it fires are designed and manufactured for one purpose — the damage or destruction of the objects of their targeted aim, be they beer bottles, tin cans, paper targets, or living beings. IMO, a firearm comes quite close enough to the logic of the “inherently dangerous instrumentality” to warrant rational regulation (slippery slope hand-wringing by 2nd Amendment paranoid “gun enthusiasts” aside). That this does not happen owing principally to the political power of the NRA is an outrage.

The scale and frequency of mass killings have been increasing, and this is likely to continue. One reason — but just one — is that weapons are always getting more lethal. One of the next technical innovations in small arms will be the use of artificial intelligence (AI) to improve the aiming of weapons. There is no reason for civilians to have this technology and we should ban it now…

Good grief.

Hey, chill, the "Tracking Point XS1" is merely an improved accuracy deer rifle, just a 21st century musket. Pay no attention to the heat vent barrel outer cover.

When Russian forces stormed the school held hostage by Chechen terrorists, over 300 people died. The Beslan school siege wasn’t the worst terrorist attack arithmetically – the fatalities were only a tenth of September 11th. What made the school siege particularly gruesome was that many who died, and died in the most gruesome manner, were children.

There’s something particularly distressing about kids being massacred, which can’t be quantified mathematically. You either get that point or you don’t. And the famed Chechen rebel, Shamil Basayev, got it. Issuing a statement after the attack Basayev claimed responsibility for the siege but called the deaths a “tragedy.” He did not think that the Russians would storm the school. Basayev expressed regret saying that he was “not delighted by what happened there.” Basayev was not known for contrition but death of children doesn’t look good even for someone whose modus operandi was in killing as many as possible.

There’s a code even amongst terrorists – you don’t slaughter children – it’s ok flying planes into big towers but not ok deliberately killing children. Of course, neither is ok but the point is that even the most immoral of our species have a moral code. Strict utilitarians won’t understand this moral code. Strict utilitarians, or rational amoralists, accord significance by multiplying the number of life years lost by the number died, and whether a death from medical error or of a child burnt in a school siege, the conversion factor is the same. Thus, for rational amoralists sentimentality specifically over children dying, such as in Parkland, Florida, in so far as this sentimentality affects policy, must be justified scientifically.

The debate over gun control is paralyzed by unsentimental utilitarianism but with an ironic twist – it is the conservatives, known to eschew utilitarianism, who seek refuge in it. After every mass killing, I receive three lines of reasoning from conservatives opposed to gun control: a) If you restrict guns there’ll be a net increase in crimes and deaths, b) there’s no evidence restricting access to guns will reduce mass shootings, and c) people will still get guns if they really wish to. This type of reasoning comes from the same people who oppose population health, and who deeply oppose the sacrifice of individuals for the greater good, i.e. oppose utilitarianism…

My ailing daughter (who underwent bone scans today) is now in fairly constant appreciable pain from her worsening Stage IV pancreatic cancer. She gets by with morphine, and MS- and Oxycontin. Sessions can go to Hell.

Attorney General Jeff Sessions is blaming an old foe of his for the opioid crisis: marijuana.

Speaking at the Heritage Foundation to the Reagan Alumni Association this week, Sessions argued that cutting prescriptions for opioid painkillers is crucial to combating the crisis — since some people started on painkillers before moving on to illicit opioids like heroin and fentanyl. But then he expanded his argument to include cannabis.

“The DEA said that a huge percentage of the heroin addiction starts with prescriptions. That may be an exaggerated number; they had it as high as 80 percent,” Sessions said. “We think a lot of this is starting with marijuana and other drugs too.”

It’s true that, historically, a lot of opioid addiction started with prescribed painkillers — although that's changing. A 2017 study in Addictive Behaviors found that 51.9 percent of people entering treatment for opioid use disorder in 2015 started with prescription drugs, down from 84.7 percent in 2005. And 33.3 percent initiated with heroin in 2015, up from 8.7 percent in 2005.

Where Sessions, who once said that “good people don’t smoke marijuana,” went wrong is his suggestion that marijuana leads to heroin use — reiterating the old gateway drug theory…

As the nation grapples with a worsening opioid crisis, a new report suggests that drug makers provided substantial funding to patient advocacy groups and physicians in recent years in order to influence the controversial debate over appropriate usage and prescribing.

Specifically, five drug companies funneled nearly $9 million to 14 groups working on chronic pain and issues related to opioid use between 2012 and 2017. At the same time, physicians affiliated with these groups accepted more than $1.6 million from the same companies. In total, the drug makers made more than $10 million in payments since January 2012.

“The fact that these same manufacturers provided millions of dollars to the groups suggests, at the very least, a direct link between corporate donations and the advancement of opioid-friendly messaging,” according to the report released on Monday night by U.S. Sen. Claire McCaskill, who has been probing opioid makers and wholesalers…

UPDATE: SPEAKING OF "EVIDENCE"

Relatedly, from ScienceBasedMed.org,

Answering Our Critics – Again!Critics of Science-Based Medicine keep making the same old tired arguments, despite the fact that their arguments have been repeatedly demolished. Here is a list of recurrent memes, with counterarguments.

Instead of a new post this week I decided to recycle and revise what I wrote about Answering Our Critics a few years ago, here and here.I thought it was time to visit this issue again, because our critics didn’t get the message. They are still flooding the Comments section with the same old tired arguments we have debunked over and over.

Some people don’t like what we have to say on Science-Based Medicine. Some attack specific points while others attack our whole approach. Every mention of complementary and alternative medicine (CAM) elicits protests in the Comments section from “true believer” users and practitioners of CAM. Every mention of a treatment that has been disproven or has not been properly tested elicits testimonials from people who claim to have experienced miraculous benefits from that treatment.

Our critics keep bringing up the same old memes, and I thought it might be useful to list those criticisms and answer them all in one place…

ADD YET ANOTHER BOOK TO THE PILE

Heard this author interviewed on NPR's "Fresh Air" yesterday in the car while taking my daughter to Kaiser for a bone scan px.

UPDATE

I downloaded Kate Bowler's new book and read it straight through. Riveting. I will have plenty to cite and say about it shortly. Stay tuned.

Tuesday, February 6, 2018

Can Computers Learn Like Humans?The world of artificial intelligence has exploded in recent years. Computers armed with AI do everything from drive cars to pick movies you'll probably like. Some have warned we're putting too much trust in computers that appear to do wondrous things.

But what exactly do people mean when they talk about artificial intelligence?

It's hard to find a universally accepted definition of artificial intelligence. Basically it's about getting a computer to be smart — getting it to do something that in the past only humans could do.One key to artificial intelligence is machine learning. Instead of telling a computer how to do something, you write a program that lets the computer figure out how to do something all on its own…

From THCB:

Medicine Is a Profession That is Rapidly Losing Control of Its ToolsBy ADRIAN GROPPER, MDArtificial Intelligence hype and reality are everywhere. However, the last month or two has seen some thoughtful reflection. HHS / ONC announced “Hype to Reality: How Artificial Intelligence (AI) Can Transform Health and Healthcare” referencing a major JASON report “Artificial Intelligence for Health and Health Care [PDF -817 KB],”. From a legal and ethical perspective, we have a new multinational program: “PMAIL will provide a comparative analysis of the law and ethics of black-box personalized medicine,…”. Another Harvard affiliate writes “Optimization over Explanation” subtitled “Maximizing the benefits of machine learning without sacrificing its intelligence”. Meanwhile, an investigative journalism report from the UK “Google DeepMind and healthcare in an age of algorithms”, “…draws a number of lessons on the transfer of population-derived datasets to large private prospectors, identifying critical questions for policy-makers, industry and individuals as healthcare moves into an algorithmic age”…

Artificial intelligence and automation outsources even more of our cognitive functions to machines. What does this mean for art, for relationships — even for our connection to a higher being? What does it mean to be human in the age of the machine?

Comes with audio versions as well. Nice.

From the first post:

From Mining to Meaning

If you use digital devices, AI is already being sicced on the grotesque bricolage that is your life to eliminate potential sources of “friction” — a tech-speak jargon term that means roughly “whatever grinds your gears.”Whether it’s by monitoring your calorie intake, presenting you with “optimal” romantic prospects, or making it easier to spend a fortune on Amazon, algorithms are even now insinuating themselves into your every existential crack and crevice like so many squirts of WD-40.The possibility of using AI to eliminate diseases is undeniably exciting. Excising problems like cancer from society would make for a better future. But is maximizing efficiency the only way to add value to the world?Most people don’t see the world and its inhabitants simply as a resource to be mined more or less effectively, nor do we tend to think that human value is exhausted by the efficiency or otherwise of this resource mining. Sometimes we just want to make sense of things: to look closely at the world, grasp some pattern in it, and articulate its significance, without some further goal in mind. This desire is what drives people to become scholars, but it’s also why people look at art, listen to music, or strive to build relationships with their grandchildren. If a concern for efficiency is a big part of what makes us human, our desire to grasp significance and share meaningful experiences with others is just as crucial.Like a world without cancer, a more thoughtful, artistic, and compassionate future strikes us as an unequivocal Good Thing. But adding this kind of value to the world requires something more than maximizing efficiency. Anyone who tries to “hack” being a thoughtful scholar, or a good friend, is kind of missing the point…

Robots have transformed industrial manufacturing, and now they are being rolled out for food production and restaurant kitchens. Already, artificial intelligence (AI) machines can do many tasks where learning and judgment is required, including self-driving cars, insurance assessment, stock trading, accounting, HR and many tasks in healthcare. So are we approaching a jobless future, or will new jobs replace the ones that are lost?

According to the optimistic view, our current phase of increasing automation will create new kinds of employment for those who have been made redundant. There is some historical precedent for this: Over a hundred years ago, people feared that the automobile revolution would be bad for workers. But while jobs related to horse-drawn carriages disappeared, the invention of the car lead to a need for automobile mechanics; the internal combustion engine soon found applications in mining, airplanes and other new fields.

The difference, however, is that today’s AI technology aims to replace the human mind, not simply make industry more efficient. This will have unprecedented consequences not predicted by the advent of the car, or the automated knitting machine…

Everyone seems to be writing about the recently announced effort by Amazon, Berkshire Hathaway, and JP Morgan Chase to attack their employee health costs. It is certainly newsworthy, and I am generally interested in whatever Amazon may do in healthcare.

They may very well have some success with this effort, but until I read a positive story about employee working conditions at Amazon, I’m going to be skeptical that any disruption in healthcare they accomplish with it is something that I shouldn’t be worried about.

So, instead, I’m going write to about why we can’t recognize our own typos, and what that means for our health.

As Wired summarized the problem a few years ago: “The reason we don’t see our own typos is because what we see on the screen is competing with the version that exists in our heads.” They go on to explain that one of the great skills of our big brains is that we build mental maps of the world, but those maps are not always faithful to the actual world.

As psychologist Tom Stafford explained: “We don’t catch every detail, we’re not like computers or NSA databases. Rather, we take in sensory information and combine it with what we expect, and we extract meaning.”

Thus, typos.

Unfortunately, the same is often true with how we view our health. We don’t think we’re as overweight as we are. We think we get more exercise than we do. We think our nutrition is better than it is. Overall, we think we’re in better health than we probably are.

Over the past few decades, the U.S. has been suffering “epidemics” of obesity, diabetes, asthma, and allergies, to name a few. Over half of adults now have one or more chronic conditions. Yet two-thirds of us still report being in good or excellent health, virtually unchanged for at least the last twenty years.

Something doesn’t jibe…

Hmmm...

I'm reminded of the old QA auditor's saying, "you get what you INspect, not what you EXpect."

Dear primary care doctor, Jeff Bezos is about to devour your lunch. All of it. And then he’ll eat the table, the plates, the napkins and the utensils too, so you’ll never have lunch ever again. Oh yeah, and they’ll also finally disrupt and fix health care once and for all, because enough is enough already. Mr. Bezos, it seems, got together with two of his innovator buddies, Warren Buffet from Berkshire Hathaway and Jamie Dimon from J.P. Morgan, and they are fixing up to serve us some freshly yummy and healthy concoction.Let’s call it Ambergan for now.

This is big. This is huge. It comes from outside the sclerotic “industry”. And it’s all about technology. The founders are no doubt well versed in the latest disruption theories and Ambergan will be a classic Christensen stealth destroyer of existing markets. When the greatest investor that ever-lived combines forces with the greatest banker in recent memory and the premier markets slayer of all times, who happens to be the richest man on earth, all to bring good things to life (sorry GE), nothing but goodness will certainly ensue.

Everybody inside and outside the legacy health care industry is going to write volumes about this magnificent new venture in the coming days and months, so I will leave the big picture to my betters. But since our soon to be dead industry has been busy lately bloviating about the importance of good old fashioned, relationship based primary care, perhaps it would be useful to understand that Ambergan is likely to take the entire primary care thing off the table and stash it safely in the bottomless cash vaults of its founders. It’s not personal, dear doctor. It’s business. Ambergan will be your primary care platform and you may even like it…

LOL. Read all of it.

The Cherry on top:

"The Amazon platform IS the network, and there will be terms, conditions, stars and promotions. There certainly are many legacy obstacles to overcome, and perhaps that is why Amazon couldn’t or wouldn’t go it alone. Throwing highly regulated markets wide open requires two strong lobbying arms, and a federal government willing to play fast and loose. The stars are indeed perfectly aligned for the first true disruption of our health care since 1965."

FEB 9TH UPDATE

Happy Birthday to me (72 today). What's the joke? "If I'd known I was gonna live this long, I'd have taken better care of myself."

apropos of the overall topic of this post, another must-read has just come to my attention, via my latest issue of Science Magazine, in a book review entitled "The fetishization of quantification."

From the Amazon blurb:

How the obsession with quantifying human performance threatens our schools, medical care, businesses, and government

Today, organizations of all kinds are ruled by the belief that the path to success is quantifying human performance, publicizing the results, and dividing up the rewards based on the numbers. But in our zeal to instill the evaluation process with scientific rigor, we've gone from measuring performance to fixating on measuring itself. The result is a tyranny of metrics that threatens the quality of our lives and most important institutions. In this timely and powerful book, Jerry Muller uncovers the damage our obsession with metrics is causing--and shows how we can begin to fix the problem.

Filled with examples from education, medicine, business and finance, government, the police and military, and philanthropy and foreign aid, this brief and accessible book explains why the seemingly irresistible pressure to quantify performance distorts and distracts, whether by encouraging "gaming the stats" or "teaching to the test." That's because what can and does get measured is not always worth measuring, may not be what we really want to know, and may draw effort away from the things we care about. Along the way, we learn why paying for measured performance doesn't work, why surgical scorecards may increase deaths, and much more. But metrics can be good when used as a complement to—rather than a replacement for—judgment based on personal experience, and Muller also gives examples of when metrics have been beneficial.

Complete with a checklist of when and how to use metrics, The Tyranny of Metrics is an essential corrective to a rarely questioned trend that increasingly affects us all.

'eh? "Data, Learning, Experience, Perception, Meaning..."

Frrom the Science Magazine (non-paywalled) summary:

SummaryAlthough the numbers whose "tyranny" forms the subject of Jerry Muller's timely book share some of the attributes of scientific measurement, their purposes are primarily administrative and political. They are designed to be incorporated into systems of what might be called "data-ocracy," often for the sake of public accountability: Schools, hospitals, and corporate divisions whose numbers meet or exceed their goals are to be rewarded, whereas poor numbers, taken to imply underperformance, may bring penalties or even annihilation. In The Tyranny of Metrics, Muller shows how teachers, doctors, researchers, and managers are driven to sacrifice the professional goals they value in order to improve their numbers.

Yeah. While, hey, I'm a long-time "quant guy," a "QI guy," I've had the Brent James training ("if you can't measure it, you can't improve it"), I too have concerns that the phrase "data-driven" can often mean putting your brain in "park." One of the cautions regarding "machine learning" goes to the concern that the machines will "learn" all of our bias errors.

The Science Magazine book review concludes:

In 1975, the American social psychologist Donald Campbell and the British economist C. A. E. Goodhart articulated independently the principle that reliance on measurement to incentivize behaviors leads almost inevitably to a corruption of the measures. Muller explains the logic of this corruption and defends, in place of indiscriminate numbers, an ideal of professional knowledge and experience.

Measurement, he concludes, can contribute to better performance, but only if the measures are designed to function in alliance with professional values rather than as an alternative to them. Good metrics cannot be detached from customs and practices but must depend on a willingness to immerse oneself in the work of these institutions.

Add another book to the stash.

ERRATUM

Speaking of "data," heard this in the car yesterday. The new "Panopticon":

Monday, January 29, 2018

Back when I was with the REC, I had some clinics on Practice Fusion. It was OK. They gave us all "sandbox" "registered user" accounts so we could kick the WKFL tires -- as did a number of other vendors.

Most of my caseload was eCW, and I had to be up to speed on about a dozen others.

I didn't care all that much for PF, but my docs seemed to like it. Interesting story on them of late.

When the healthcare information technology (IT) firm Allscripts announced this month its $100 million cash deal to acquire the cloud-based electronic health records (EHR) vendor Practice Fusion, the Chicago-based company said part of its rationale was the desire to grow its reach among smaller providers.

The deal highlights what has been a persistent challenge for many EHR vendors: penetrating the small-practice market…

Allscripts had 2016 revenues of $1.55 billion, and although it’s still significantly smaller than competitors like Epic and Cerner, the company has been growing its footprint in the hospital sector, most notably through its August 2017 acquisition of McKesson Corp.’s Enterprise Information Solutions business.

Allscripts believes the deal will be a win for Practice Fusion’s clients, as they say their acquisition will add value and additional services to its offerings. That could help the merged company stand out in the crowded field.

However, Allscripts won’t necessarily need to alter its services to help smaller practices…

Allscripts CEO Paul Black issued a prescient ultimatum in October on a stage at Health 2.0.

"Either we need to disrupt ourselves or somebody in this room will come in and disrupt us because it's too easy now that everything is digital," he said.

Allscripts revealed this week it had purchased its cloud-based competitor Practice Fusion for $100 million.

Practice Fusion once touted a $1 billion valuation and toyed with going public. In the end, the company was sold for less than the investment capital it raised. Venrock investor Bob Kocher called the news "disappointing."

The story points to a larger consolidation trend sweeping across the industry. A confluence of factors is driving the pairings-up, including exhausted Meaningful Use funds, a tapped EHR market and shift toward consumer-centric models. That's driving larger players like Allscripts to hunt for new revenue streams with smaller targets to add code, staff or customer reach.

But the larger companies can't rest on their laurels; new entrants — some major players the likes of Apple — are lurking in every garage in Silicon Valley.

"The EHR market is saturated [and] consolidation is very clear," Kenneth Kleinberg, vice president of research at Chilmark Research, told Healthcare Dive. "Four, five [or] six players is about what we're looking [at] for 2018.”…

Be interesting to see what shakes out this year. There's a ton of ambulatory EHRs out there, but the Meaningful Use gravy train is now over.

The EHR griping continues, too.

Highly Experienced Physicians Leaving Medicine Due to Electronic Medical RecordsYves here. We’ve posted off and on for at least the past five years, via the dogged coverage at the Health Care Renewal website, over the way that electronic medical records are undermining the delivery of health care. Some readers instinctively reject that idea, but that is due to not understanding that these systems are entirely about billing, not about diagnosis or treatment, and regularly force doctors to navigate through numerous irrelevant screens before they get to the parts that are relevant to their patient. That wastes time and dilutes the doctor’s focus…

Paper is not better. And -- tedious to keep repeating -- that is not to assert that EHRs are adequately aligned uniformly in support of clinical cognition, clinical WKFL, and patients needs.
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Friday, January 26, 2018

Probably paywalled. I didn't check. I'm an AAAS member. You should be as well.

Accumulating evidence indicates that dysregulation of microbiota-host interactions associates with various diseases, including inflammatory bowel diseases (IBDs), colorectal cancer, diabetes, and liver cirrhosis (1). Recently, research has generated paradigm shifts in concepts about the interactions between bacteria and cancer therapeutic drugs. For example, bacteria modulate the antitumor efficacy in preclinical models of various chemotherapies (2–4) and immunotherapeutic agents (5, 6). Conceptually, these findings suggest that bacteria-mediated interactions with the immune system are essential for optimal drug efficacy. However, there is limited information regarding the functional impact of the composition of the human microbiome and therapeutic outcomes in cancer patients. On pages 91, 97, and 104 of this issue, Routy et al. (7), Gopalakrishnan et al. (8), and Matson et al. (9), respectively, address this important issue and demonstrate that patients can be stratified into responders and nonresponders to immunotherapy on the basis of the composition of their intestinal microbiomes, suggesting that microbiota should be considered when assessing therapeutic intervention…

[Conclusion] The relationship between microbial communities and antitumor drug responses are complex. On the one hand, depletion of selective bacterial taxa by means of antibiotic exposure or other stressor conditions may diminish immunotherapy responses. On the other hand, the presence of specific microorganisms in local or distant sites may interfere with treatment through metabolic activities (14). For example, bacteria of the Enterobacteriaceae family, such as Escherichia coli strains, decrease efficacy of the chemotherapeutic agent gemcitabine by metabolizing and deactivating the active form of the drug, thereby negatively interfering with tumor response (15). Therefore, the presence of specific strains of bacteria may be able to modulate cancer progression and therapeutics, raising the possibility that precision medicine directed at the microbiota could inform physicians about prognosis and therapy. One could view the microbiota as a treasure trove for next-generation medicine, and tapping into this network may produce new therapeutic insights.

My daughter is now on a 3-weeks-on/1-week-off chemo regimen of Abraxane+Gemcitabine. I rather doubt they're assaying her gut microbiome. "Next generation medicine."

REGARDING "ECONOMICS"

Given that Davos is about "economics" and the foregoing video focuses on innovations that will hopefully bring us effective "precision medicine," one of my new reads seems quite timely.

Introduction: The Innovation Economy

The Innovation Economy begins with discovery and culminates in speculation. Over some 250 years, economic growth has been driven by successive processes of trial and error and error and error: upstream exercises in research and invention, and downstream experiments in exploiting the new economic space opened by innovation. Each of these activities necessarily generates much waste along the way: dead-end research programs, useless inventions and failed commercial ventures. In between, the innovations that have repeatedly transformed the architecture of the market economy, from canals to the internet, have required massive investments to construct networks whose value in use could not be imagined at the outset of deployment. And so at each stage the Innovation Economy depends on sources of funding that are decoupled from concern from economic return…

Monday, January 22, 2018

(WASHINGTON) — Reinforcing its strong connection with social conservatives, the Trump administration announced Thursday a new federal office to protect medical providers refusing to participate in abortion, assisted suicide or other procedures on moral or religious grounds.Leading Democrats and LGBT groups immediately denounced the move, saying “conscience protections” could become a license to discriminate, particularly against gay and transgender people.The announcement by the Department of Health and Human Services came a day ahead of the annual march on Washington by abortion opponents, who will be addressed via video link by President Donald Trump. HHS put on a formal event in the department’s Great Hall, with Republican lawmakers and activists for conscience protections as invited speakers…

The Trump administration just made it easier for doctors to deny care to women and LGBT people. On Thursday, the Department of Health and Human Services announced a new division devoted to “conscience and religious freedom” that will protect health workers who refuse to treat patients because of moral or religious objections—a move that critics fear could jeopardize access to birth control and abortion, hormone therapy for transgender people, fertility treatment for lesbian couples, or medications for HIV and AIDS.

In a press conference about the new Conscience and Religious Freedom Division, Roger Severino, a senior HHS official, said it was necessary to shield medical staffers who deny care on religious grounds, comparing their situation with that of Jews who were slaughtered during the Holocaust and Martin Luther King Jr. in his quest for racial justice…

WHEN MARCI BOWERS consults with her patients, no subject is off limits. A transgender ob/gyn and gynecologic surgeon in Burlingame, California, she knows how important it is that patients feel comfortable sharing their sexual orientation and gender identity with their doctor, trust and honesty being essential to providing the best medical care. But Bowers knows firsthand that the medical setting can be a challenging place for patients to be candid. That for LGBT people, it can even be dangerous.

"I know from talking with patients that they're often denied services, not just for surgery and hormone therapy, but basic medical care," Bowers says. "I've had patients show up in an emergency room who were denied treatment because they were transgender."

Experiences like these are what make the creation of a new "Conscience and Religious Freedom" division within the US Department of Health and Human Services so troubling. Announced last week by acting secretary of HHS Eric Hargan, the division's stated purpose is to protect health care providers who refuse to provide services that contradict their moral or religious beliefs—services that include, according to the division's new website, "abortion and assisted suicide."

But the division's loose language could leave room for physicians to provide substandard care to LGBT patients—or abstain from treating them altogether…

In 2014, a 27-year-old nurse-midwife named Sara Hellwege applied for a job at Tampa Family Health Centers, a federally qualified health center. She was a member of the American Association of Pro-Life Obstetricians and Gynecologists, a professional association that opposes abortion.

“Due to religious guidelines,” Hellwege wrote to the clinic’s HR director, Chad Lindsey, in an email, “I am able to counsel women regarding all forms of contraception, however, cannot Rx [prescribe] it unless pathology exists—however, have no issue with barrier methods and sterilization.”

In his response, Lindsey cited the health center’s participation in a government family-planning program, Title X, as grounds for rejecting her as an applicant. “Due to the fact we are a Title X organization and you are a member of AAPLOG, we would be unable to move forward in the interviewing process,” he wrote. The clinic did not, he added, have any positions available for practitioners who wouldn’t prescribe birth control.

Hellwege sued through the Alliance Defending Freedom, a Christian legal group, on the grounds that a federally funded clinic should not be able to disqualify applicants because they “object to providing abortifacient contraceptives.”

The case settled, and on Thursday, Hellwege reappeared on the national scene: She spoke at the national press conference announcing the creation of a Conscience and Religious Freedom Division at the Department of Health and Human Services…

___

The directly relevant Constitutional clauses:

Amendment ICongress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof; or abridging the freedom of speech, or of the press; or the right of the people peaceably to assemble, and to petition the government for a redress of grievances.

Amendment XIVSection 1.All persons born or naturalized in the United States, and subject to the jurisdiction thereof, are citizens of the United States and of the state wherein they reside. No state shall make or enforce any law which shall abridge the privileges or immunities of citizens of the United States; nor shall any state deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.

SEVERINO: Well, it comes down to the president's May 4, 2017, executive order, which was a turning point. He said that we're going to vigorously enforce federal law protecting religious freedom. He said, we're a nation of tolerance, and we'll not allow people of faith to be targeted, bullied or silenced anymore. And this is just a natural outgrowth of that. We have a lot of statutes and laws on the books that protect conscience. They protect religious freedom. They have not been enforced as they deserve to be enforced, and this is a crucial civil right that is now getting the attention that has been long overdue.

The mind boggles considering where to begin with this autocratic/theocratic mendacity. Among other things, we will examine VP Pence's Indiana Senate Bill 101 (SB0101), which Mr. Piety eagerly signed into law while governor (I call it "The Christian Pizza Protection Act"), and "FADA" (HR 2802, the federal "First Amendment Defense Act"). I have dubbed this beaut "The Show-Your-One-Man-One-Woman-Marriage-License-At-Marriott-Checkin" bill).

Recall my mention of thisback in December while commenting on the Trump Tax Cut bill Senate-House reconciliation draft:

The "Personhood at Conception / Unborn Child Tax Credit" provision in the House bill got removed -- “an unborn child means a child in utero, and the term child in utero means a member of the species homo sapiens, at any stage of development, who is carried in the womb.“

"Congress shall make no law respecting an establishment of religion, or prohibiting the free exercise thereof."

Amendment XIVSection 1.

"No state shall make or enforce any law which shall
abridge the privileges or immunities of citizens of the United States, unless such privileges contravene the provisions of revised Amendment I."

Hey' we're "cutting government regulations. Let's just cut out that pesky 'free press' part of the First Amendment."

In short, the thrust of these kinds of unconstitutional forays is to subordinate the equal protection provisions of the 14th Amendment to the religion clauses of the 1st.

Donald Trump has made scant secret of his lust for infringing on inconvenient "free speech." to wit, as reported by the intrepid Marcy Wheeler recently reported regarding the recently renewed FISA law:

…it’s the unreviewable authority for Jeff Sessions bit that is the real problem.

We know, for example, that painting Black Lives Matter as a national security threat is key to the Trump-Sessions effort to criminalize race. We also know that Trump has accused his opponents of treason, all for making critical comments about Trump.

This bill gives Sessions unreviewable authority to decide that a BLM protest organized using or whistleblowing relying on Tor, discovered by collection done in the name of hunting Russian spies, can be referred for prosecution. The fact that the underlying data predicating any prosecution was obtained without a warrant under 702 would — in part because this bill doesn’t add teeth to FISA notice — ensure that courts would never learn the genesis of the prosecution. Even if a court somehow managed to do so, however, it could never deem the domestic surveillance unlawful because the bill gives Jeff Sessions the unreviewable authority to treat dissent as a national security threat...

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With respect to this whole "religious liberty" thing and civil (including patient) rights, I am reminded of passages in Ann Neumann's brilliant book.

After the 1973 Roe v. Wade decision, Catholic and Evangelical leaders formed an alliance that had previously been unthinkable. Part backlash to the liberalizing politics of the 1960s and early 70s, part enemy-of-my-enemy-is-my-friend, part trepidation at declining church enrollment and restructuring of the nuclear family, Catholics and Evangelicals found that their cooperation on so-called traditional values was a holy alliance. “This political and cultural realignment even helped melt divisions among Protestants, Catholics, and Jews, as religious identity came to matter less than one’s moral and political positions regarding a host of key issues, including abortion, premarital sex, birth control, divorce, and homosexuality,” writes Petro in After the Wrath of God. It intertwined grassroots church networks, priests who were willing and able to pressure legislators, international influence (for example, in US health policy abroad, that excluded condoms or abortion access), media empires (from Trinity Broadcasting Network to Jim Bakker and Oral Roberts), and American religious fervor. Since the 1970s, the Christian Right has ebbed and flowed, with various organizational forces rising to prominence and falling apart. From Jerry Falwell’s Moral Majority, founded in 1979, to Pat Robertson’s Christian Coalition, founded in 1989, their “successes at political mobilization— pushing apolitical religious conservatives to become voters, voters to become activists, and activists to become candidates— have become woven into the fabric of our national political life, particularly within the GOP,” wrote journalist and scholar Frederick Clarkson, a senior fellow at Political Research Associates, on its website in 2013.

Rather than measure this group’s achievements by the number of politicians who have risen to power, Clarkson writes, “Its greatest success, in fact, has been somewhat under the radar: creating an institutional network that fosters young conservatives and encourages them to translate conservative ideas into public policy.” In 2009, prominent conservative Catholic and Protestant leaders signed the Manhattan Declaration, a manifesto declaring, “We are Christians who have joined together across historic lines of ecclesial differences to affirm our right— and, more importantly, to embrace our obligation— to speak and act in defense of these truths. We pledge to each other, and to our fellow believers, that no power on earth, be it cultural or political, will intimidate us into silence or acquiescence.” (The entire text can be found online at manhattandeclaration.org.)

In the declaration’s formulation, legalized abortion is a keystone on which other issues like same-sex marriage, contraception, stem cell research, and euthanasia rest; the challenge to stop such corruptions can be understood through the study of the shifting definition of religious liberty in the United States.

According to Clarkson, these groups are invested in the “idea that those who favor reproductive choice and marriage equality are non-religious or anti-religious, and thus are prepared to trample the religious liberty of everyone.” Religious liberty is now being used as a defense of a religious ideology’s existing authority, at the expense of others’ diversifying worldviews and rights; it’s become an accusation that those who don’t agree with a particular frame are simply wrong, fallen, depraved, or misguided.

The early foundational idea of religious liberty— in theory, if not in practice— was meant to protect individual conscience, to prevent authoritative powers of any sort from dictating the religious beliefs of citizens. But as Clarkson writes,

The signers of the [Manhattan] Declaration cast themselves as patriots challenging “tyranny” in the tradition of the American Revolution and as warriors for social justice. While laying claim to the mantle of the Revolution is not new or unique to this group, the Declaration has ratcheted up the seriousness with which Christian Right leaders are treating the nature of the confrontation. “We will fully and ungrudgingly render to Caesar what is Caesar’s,” they conclude. “But under no circumstances will we render to Caesar what is God’s.”

By reinterpreting religious liberty (or stubbornly adhering to existing and/ or idealistic forms), the Manhattan Declaration and its signatories claim their moral values to be rightly privileged above all others. In an increasingly diverse country where a multitude of moralities— religious and otherwise— exist, “pro-life” organizations are brazenly working to shape laws, systems of power, and national conversations to their own beliefs...

The crux of FADA (still a [for now dormant] bill, from the 114th Congress, not yet enacted):

SEC. 3. PROTECTION OF THE FREE EXERCISE OF RELIGIOUS BELIEFS AND MORAL CONVICTIONS. (a) IN GENERAL.—Notwithstanding any other provision of law, the Federal Government shall not take any discriminatory action against a person, wholly or partially on the basis that such person believes or acts in accordance with a religious belief or moral conviction that marriage is or should be recognized as the union of one man and one woman, or that sexual relations are properly reserved to such a marriage.

A transparent attempt to end-run the SCOTUS ruling on "marriage equality."

Pence's Indiana SB0101 comprises a much broader overreach:

"Religion" is anything the claimant says it is (and consequently not a federally unconstitutional "Establishment of Religion");

A protected "Religious Person" spans the gamut from actual persons through for-profit corporations;

The so-called "religious rights" are presumptive (though, tell it to Sikhs or Muslims, etc);

The state is required to come to the legal aid of "religiously burdened" claimants (e.g., Pizza shops or florists owned by Fundie "Christians").

I obviously don't think so. I (mostly) tend to choose my words with care. While I have no doubt of the frequently genuine -- if often inadequately reflective and rational -- moral convictions of numerous clinical "protectees" within the targeted purview of this HHS initiative, this new HHS undertaking is anything but that which might be characterized by the phrase "religious tolerance."

It is dispositively (and unconstitutionally) theocratically sectarian, transparently intended to circumscribe the civil rights of a breadth of marginalized cohorts (including those of women writ large).
_____________

"Who knew health care could be so complicated?"

Of ongoing interest

Cogito ergo sum

Will "artificial intelligence" (#AI) soon become simply "intelligence" capable of "reasoning" like humans?

Kind words from Dr. Jerome Carter

"Recently, I have begun reading Bobby Gladd’s KHIT.org blog. His posts (stories? vignettes?) are thoughtful and somehow put into perspective all the nonsense that happens in HIT – informative and thoroughly satisfying."

Total Pageviews

An American Sickness

On the harmful and persistent fragmentation of health care delivery

On the American way of death

An important book, IMO

The American Association for the Advancement of Science

AAAS.org

The Union of Concerned Scientists

UCSUSA.org

Health 2.0 SF Chapter

Coming soon

I've been around healthcare since 1993. Medicare QIO hospitalization outcomes analyst and network administrator, academic, next-of-kin caregiver (late daughter, late parents), and now, at 71, a Medicare bene having just finished up my own cancer treatment. This book, based in part on the long essay I wrote during my daughter's fatal illness (click Sissy's photo above), will reflect on that multifaceted journey of more than two decades.

An important read with implications for clinical cognition and workflow

Excellent physical neuroscience and neuropsychology findings on the evolution and functionality of the human brain and the adverse impact of information technology.

Northern California Cancer Support Community

Serving the Bay Area via the proven "Wellness Community" model established by the late Dr. Harold Benjamin.

Brave New Health

Brave New Health Foundation was created to help raise awareness about the important problems in the practice of medicine today. These fundamental problems have been hidden from the public for decades, but they affect everyone -- even you. The current healthcare system leaves patients feeling powerless, medical students overwhelmed, and doctors carrying an impossible burden. This leads to diagnostic errors, bad treatment choices, exploding healthcare costs, and preventable harm.

"Interoperability"?

Commonwell Health Alliance

"For health IT to work, it must be inherently interoperable. There are too many silos across a fragmented information system; vital data is [sic] trapped, creating inefficiency, cost and risk. It’s absolutely critical for interoperability to be built into our health IT systems, not bolted on as an afterthought. What’s more, without interoperability, future innovations in health IT are limited and work only in pockets, rather than benefiting the system as a whole."

BobbyG, ASQ member since 1989

An amazing, inspiring organization

BobbyG on Twitter

BobbyG on Pinterest

Electonic Frontier Foundation

New technologies are radically advancing our freedoms but they are also enabling unparalleled invasions of privacy.

This will never win a Grammy

Published on July 15, 2012: I was inspired to write and record this after the Supreme Court ruling narrowly upholding the PPACA, pejoratively known as "ObamaCare." Thanks to my bro' Lenny Lopez for the harmonies. Thanks to Apple for your awesome GarageBand app. The "Epistemic Hairball All Star Shoe Band" here is nothing but a multitrack sequence of Garageband library loops.

3 Still Standing

I met these folks through my long-time friend Gail Simon, the widow of my 60's bass player the late Jose Simon. Jose went on to co-found the acclaimed "San Franciso Comedy Day in the Park." This is a documentary about the scuffling lives of 3 fine stand-up comics from the era. Produced by award-winning documentary filmmakers Donna LoCicero and Robert Campos. It is very funny, poignantly so.

ThedaCare Center for Healthcare Value

CreateValue.org

Health 2.0

The conference. The media network. The innovation community.

Healthcare Information Management Systems Society

Advancing the best use of information and management systems for the betterment of health care.

International Association of Privacy Professionals

The largest and most comprehensive global information privacy community and resource.

Getting at truth?

Very interesting paper (PDF)

Down in the Weeds'

You owe it to yourself to acquire, study closely, and think hard about this book. For the record; I get nothing from this unsolicited plug. I don't know these people, all I know is what I've read.

SBM

Exploring issues and controversies in the relationship between science and medicine

Another important read (pdf)

I love this kind of stuff. It sustains and humbles me. "As politicians, advertisers, salesmen, and propagandists for various political, economic, moral, religious, psychic, environmental, dietary, and artistic doctrinaire positions know only too well, fallible human minds are easily tricked, by clever verbiage... Common language—or at least, the English language—has an almost universal tendency to disguise epistemological statements by putting them into a grammatical form which suggests to the unwary an ontological statement. A major source of error in current probability theory arises from an unthinking failure to perceive this."

Joe Flower

This book is comprehensive, articulate, learned, and the most charitable of the health policy reform books I've read.

On The Mend

The Lean imperative for health care process improvement, bringing the scientific method into workflow and management. A great read. (Note, I get nothing out of touting this or any other books I cite.)

National Nurses United

MediPedia.com

Growing repository of health-related information, all of it peer-reviewed via the Wiki model

Quotes

"An economist is a person who sees something that works in practice and tries to figure out whether it will work in theory."

- J.D. Kleinke, medical economist___

"The only person who enjoys change is a baby with a wet diaper."

"Every misspent dollar in our health care system is part of somebody's paycheck.

- Brent James, M.D., M.Stat

“We could do healthcare, at markedly higher quality, for everyone in this country, without rationing or denying anybody the care that they need, without having the government dictate how doctors practice or whether hospitals could expand, at half the cost we do it now.”

- Health Care Futurist Joe Flower

Most of the sciences, unlike parts of medical science, are not concerned with the impossible. There is not complementary and alternative physics, or chemistry, or biochemistry, or engineering. These disciplines compare their ideas against reality, and, if the ideas are found wanting, abandoned."

- Mark A. Crislip, MD

"Q: How much alcohol is too much?A: More than your doctor drinks."

- a physician I once heard speak during a CME presentation

“Just because science doesn’t know everything, doesn’t mean you get to fill in the gaps with whatever fairy tale most appeals to you.”

- Dara O’Briain

'[I]t is one small step from using the computer for "helping" doctors to monitoring them, judging them, dictating to them what to do, and withdrawing payment for computer non-compliance. The use of computer data is a multi-edged sword. It can be used for the "good," facilitating diagnosis and treatment and making it more accurate and up-to-date, and for “evil,” invading privacy, inviting security breechs, and making decisions based on the opinions of remote authorities rather than those present at the patient-doctor encounter.'

- Richard Reece, MD

“[T]here ARE statistics which are non-political. Just because The Washington Post/Fox News reports the temperature is 75 degrees doesn’t mean it’s really snowing and sunscreen is a liberal/conservative plot. Even if you earn a living being ideological.”

- Michael L. Millenson

"It is a generally a fairly convincing argument that people shouldn’t have to be subsidized to undertake a change which is in their best interest.

The reconciliation seems to be that EHR is not supposed to make a doctor’s practice more efficient and higher quality. It is supposed to make the system of care more efficient and higher quality, which is not the same thing. Those of you who took calc recall that maximizing the total of variables is not achieved by maximizing any one variable and this is a perfect example of that.

Those of you have served in combat certainly noticed that too — if everyone works as a team the unit takes fewer casualties. If you try to save your own hide, you might, but at the expense of more casualties overall."

- Al Lewis

"There are two ideas to keep in mind about Bayesian reasoning and how we tend to mess it up. The first is that base rates matter, even in the presence of evidence about the case at hand. This is often not intuitively obvious. The second is that intuitive impressions of the diagnosticity of evidence are often exaggerated."

- Daniel Kahneman, "Thinking, Fast and Slow"

"Physicians apply advanced scientific knowledge, but they must do so without the favorable conditions that experimental scientists create for themselves. Multitasking is forced on physicians, often in chaotic environments and under severe time and resource constraints."

- Lawrence and Lincoln Weed, "Medicine in Denial"

"It’s time to stop the whining about Obama care and acknowledge we already have universal health care. We just pay for it in the stupidest way possible that ensures problems are that much more disastrous and complicated when they’re finally treated."

- Mark Hoofnagle, MD, PhD

"Every act of conscious learning requires the willingness to suffer an injury to one's self-esteem. That is why young children, before they are aware of their own self-importance, learn so easily."

- Thomas Szasz, MD___

"Of course, one reason that process metrics* are so popular is that processes are much easier to define and measure than outcomes."

- The Skeptical Scalpel___

"There is an “illusion of validity” for any random data point, a seductive sense that is colored by what we hope will be true. Mountains of pharmaceutical claims are often made from mere molehills of data."

- Danielle Ofri, MD___

"Joy empowers people. It is a source of energy that enables people to hope and plan and change their lives for the better. Spend some time around someone who is relentlessly negative and how do you feel–drained, right? More and more research shows that joy is not something that just happens to you, like a bolt of lightening out of the blue. Joy is, instead, a habit to cultivate. Negative thinking and despair are the crabgrass of our souls–weeds that take root and spread, sometimes to all areas of life. Joy, in contrast, is a soul’s rose–hardy when cared for, able to put down roots over time and withstand disease and extremes. Like a rose, however, your joy can become blighted from neglect or harsh conditions. We all need to tend to our joy–to prune away the badness, and to know that, even though it may look like a prickly bare root, if you invest time in a joyous outlook, gorgeous things will bloom, even in the harshest conditions."- Dr. Jan Gurley___

"'Solutions' exist only in mathematics."

- Karen Martin___"The issue of how to regulate clinical software is, in the long run, indistinguishable from the issue of how to regulate medicine. The only difference is that medicine is practiced in the open, without secrecy, subject to peer review, and under a merit-based state license."

About Me

Cheryl D. Prince, CQA, CMQ/OE

Corporate Director of Quality, Gilbane Building Company, Concord, CA. My wife and best friend of more than four decades. Scary smart. The kindest person I ever met.

DISCLAIMER:

I write this blog wholly on my own time and my own dime. The views proffered are expressly my own as a concerned and active citizen/taxpayer (in addition to being the result of my substantive experience in the various IT fields), and in no way reflect any policy views of my former employer, notwithstanding that some of the thinking has indeed obviously been spurred by the implications of the work with which I have been doing for them.

FAIR USE POLICYI cite a ton of news and web sources spanning the breadth of relevant technical and policy domains, sometimes at substantial length. I believe I remain well within the bounds of "Fair Use," as [1] I am not doing any of this for profit, [2] I always provide attribution and links -- which, [3] far from negatively impacting any copyright holders' commercial interests, might actually increase traffic to and interest in their offerings.

Nonetheless, should I post anything of yours regarding which you have any objection, just let me know and I will remove it forthwith.